Hepatitis C treatment integrated in the Malmö Needle Exchange Program
The Malmö Needle Exchange Program integrates hepatitis C testing and treatment in a low-barrier harm reduction setting for people who use drugs. Patients received treatment for eight weeks directly at the needle exchange site, with weekly support from program nurses. The study found that 96% of those who completed treatment were cured, with very high rates of adherence to the treatment regimen. This study shows how integrating hepatitis C treatment into a harm reduction setting can reduce barriers to hepatitis C care and successfully cure hepatitis C in people who use drugs.
The Malmö Needle Exchange Program
This program delivered hepatitis C care out of the Malmö Needle Exchange Program (MNEP), a well-established program accessed by people who use drugs. It is part of the Infectious Diseases Department at Skåne University Hospital. In addition to new injection equipment, the MNEP provides education on overdose management, distributes naloxone kits and provides basic healthcare (including gynecological care) and social counselling services. The MNEP also provides referrals to addiction treatment, including opioid substitution therapy.
As part of their enrolment in the MNEP, individuals undergo regular testing for sexually transmitted and blood-borne infections. The program performs hepatitis C testing through venipuncture done onsite. Samples are tested at a central microbiology laboratory.
Participants in the hepatitis C treatment program were clients of the MNEP who had a chronic hepatitis C infection for at least 6 months and self-reported recent injection drug use. Those who also had HIV or hepatitis B co-infections were offered treatment outside of the study. Females with child-bearing potential were required to use birth control.
Treatment program at the Malmö Needle Exchange Program
Participants attended an initial visit to confirm that they had a chronic hepatitis C infection. Eligible patients were offered hepatitis C treatment, irrespective of genotype or level of liver injury. Within one week of the initial visit, patients returned to begin treatment. Liver assessment and other treatment work-up were done onsite by medical staff, including nurses and infectious disease physicians. All participants received a once-daily dose of hepatitis C medication for eight to 12 weeks.
Patients met twice with an infectious disease physician, at the beginning and the end of treatment. Throughout treatment, they met with program nurses weekly to receive their medication in a personal pill organizer and to assess adherence, check for adverse events and monitor any other medications. Program nurses reminded patients of appointments via phone calls and text messages. If patients could not be reached, the program nurses contacted rehabilitation facilities, opioid substitution clinics, their spouses or friends, or they visited the patients at their homes to follow up.
Between April 2018 and May 2019, 62 participants were screened. Of those, 50 people were eligible for the study and agreed to take part. Forty-seven patients completed treatment. Two patients chose to end treatment early and one patient was lost to follow-up.
Participants who finished treatment had very high cure rates. Forty-five out of 47 patients who completed treatment were confirmed to be cured through testing 12 weeks after completing treatment. There was one reinfection during treatment, and one individual was lost to follow-up after completing treatment.
Adherence was very high among program participants. Treatment adherence was measured weekly through the number of returned medication tablets and the number of missed daily doses self-reported by the patient. The mean adherence per week was 98% (on the basis of returned tablets), and 88% (on the basis of self-reported missed doses). No severe side effects related to hepatitis C medication were reported.
What does this mean for service providers?
This study shows that needle exchange programs can serve as a valuable location to engage people who use drugs in hepatitis C treatment with subsequent cure. Integrating hepatitis C care into harm reduction services can reduce the barrier of navigating a complex, potentially stigmatizing healthcare system to receive treatment elsewhere. Individuals regularly engaged with the needle exchange program and had built supportive, non-judgmental relationships with the staff. This helps to increase engagement and monitoring for hepatitis C treatment, and it also facilitates ongoing counselling on harm reduction and screening for reinfection.
This study also shows high cure rates for people who use drugs when care is delivered in a harm reduction setting. The authors reported that the main barrier to confirming a sustained virologic response 12 weeks after treatment was loss to follow-up rather than treatment failure. In this study, adherence to the treatment regimen was very high, because of the low-threshold, wraparound model of care, the mild side effects of hepatitis C medication and the relatively short treatment duration.
Although this study was conducted in a needle exchange program, the findings could be applied to other low-threshold, community-based services that are regularly accessed by people who use drugs. This could include overdose prevention sites, safe consumption sites, opioid substitution therapy and other harm reduction supply distribution programs.
Blomé MA, Bråbäck M, Alsterberg S et al. Hepatitis C treatment at a Swedish needle exchange program, a successful model of care — the ACTIONNE study. International Journal of Drug Policy. 2021;103407.